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2014 Police Schedule 17 pay request 12 Lease 2014 — Sch # 17 (Police Dept.) Payment Request # 2014-12 EXHIBIT A PAYMENT REQUEST FORM/ACCEPTANCE CERTIFICATE The Escrow Agent is hereby requested to pay from the Acquisition Fund established by the Escrow Agreement dated as of February 18,2014. by and among the Escrow Agent, the Lessee and Lessor,to the person or corporation designated below as Payee, the sum set forth below in payment (of all/of a portion)of the Acquisition Costs described below. The amount shown below is due and payable under a purchase order or contract with respect to the Equipment described below and has not formed the basis of any prior request for payment. In addition,the undersigned acknowledges delivery,installation and receipt in good condition,and hereby accepts the Equipment described on the attached invoices. Payee: EMP Technical Group Amount: $1,609.29 Description of Equipment.Item Cost: E-Ticket Scanners and accessories Dated: July 14, 2014 LESSEE: City of Carmel One Civic Square , ie Carmel,i 03.2 e, ,,,_, . ,.. By: Name: Diana Cordray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE MAIL CHECK TO: EMP Technical Group 15309 Stoney Creek Way Noblesville,IN 46060 PAGE I e• 1I:41. .:2.!,I: REMIT TO: Invoice pa:°�•� °°°°�°.° EMP Technical Group ▪ ,..'.. �: Noblesville,IN 46060 Date Invoice# b °:▪ . Iliti..aI:.IC 317-776-6700 EMP 7/8/2014 23367 TECHNICAL - GROUP Bill To Ship To Carmel Police Department Information&Communications Systems 3 Civic Square 31 1st Ave.NW Carmel,IN 46032 Carmel, IN 46032 ATTN:ACCOUNTS PAYABLE Attn:Greg Bedell P.O. Number Terms Ship UPS# FedEx# Ship Via F.O.B. 32072 Net 30 7/3/2014 n/a n/a Fed Ex Ground Factory Quantity Item Code Description U/M Price Each Class Amount 3 HON-1900G... Honeywell Xenon USB Scanner KIT ea 262.50 18411 787.50T (Replacing 46000SF05I Scanner Kit) 3 PJ622 BROTHER MOBILE,POCKETJET 6, ea 257.00 18411 771,00T 200-DPI,INTEGRATED USB/IRDA, ENGINE ONLY,NO BATTERY,NO DOC. SET,NO ACCESSORIES 3 LB3690 BROTHER MOBILE,CAR ea 16.93 18411 50.79T ADAPTER,CIG.PLUG FOR POCKETJET 3,3'LENGTH,REPLACES 205579 Sales Tax 0.00% 0.00 Thank you! Total $1,609.29 Phone# Fax# 30 DAY RETURN POLICY: In order for items to be eligible for return,items must be in 317-776-6700 317-219-0535 like new condition with all original unmarked packaging. ACQ CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 4/21/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Marianne Uban Hylant Group IA/C. Ext1:317-817-5136 FAX Nor317 817-5151 301 Pennsylvania Parkway,#201 -A Indianapolis IN 46280 ADRESS:marianne.uban h lant,com INSURER(S)AFFORDING COVERAGE NAIC If INSURER A:Charter Oak Fire Insurance Co 25615 INSURED CARME80 INSURER B: City of Carmel INSURER C: One Civic Square INSURERD: Carmel, IN 46032 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:970829312 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP INSR WVO POLICY NUMBER (MMIDDIYYYY) (MMIDD/YYYY) LIMITS A GENERAL LIABILITY Y ZLP14T62033 1/1/2014 1/1/2015 EACH OCCURRENCE $2,000,000 X COMMERCIAL GENERAL LIABILITY PRS( RENTED PREMISES{Ea occurrence) $50,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $Excluded PERSONAL&ADV INJURY $2,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO- JECT LOG $ A AUTOMOBILE LIABILITY H8103036P64ACOF14 1/1/2014 1/1/2015 COMBINED SINGLE LIMI f (Ea accident) $22 000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) X Comp X Coll Comp/Coll Ded $2,500 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ • DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS___._ER YIN ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) ADDITIONAL NAMED INSUREDS: CARMEL CLAY PARKS BUILDING CORPORATION; CARMEL CLAY BOARD OF PARKS& RECREATION; CARMEL REDEVELOPMENT COMMISSION; CARMEL REDEVELOPMENT AUTHORITY; CARMEL CITY CENTER COMMUNITY DEVELOPMENT CORPORATION Certificate Holder is an Additional Insured re:Various Police EquipmentNehicles CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Huntington National Bank& It's Assignors&Assignees ACCORDANCE WITH THE POLICY PROVISIONS. c/o American Lease Insurance 654 Amherst Rd., Ste. 335 AUTHORIZED REPRESENTATIVE Sunderland MA 01375 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD